HospitalInspections.org

Based on interview and record review, the facility failed to obtain informed consent from the patient's legal guardian for 1 (#5) of 6 patients reviewed regarding informed consent for treatment, resulting in the potential for less than optimal outcomes. Findings include:

On 4/3/23 at approximately 1600, phone interview with patient #5's daughter revealed that she was the patient's legal guardian and the facility staff did not contact her regarding admission to the Geropsychiatric hospital unit (behavioral health unit for patients 65 and over) and then transfers back and forth to the facility emergency department (ED). She stated that her calls went unanswered and that she did not give consent, did not know her mother's status, or where in the facility she was located.

On 4/4/23 at approximately 1330, record review with Emergency Director I and Nurse Manager G revealed that the patient was a 81-year-old female with bipolar disease, exhibiting mania and agitation. She was admitted to the Geropsychiatric Unit (Geropsych) on 9/15/22, then transferred to the facility ED on 9/16/22, then back to Geropsych unit until discharge on 9/19/22.

On 4/4/23 at approximately 1530, interview with the Geropsych Director Y, Geropsych Clinical Nurse Manager Z, and Geropsych Social Worker AA revealed that the patient had fallen in the Geropsych Unit and was transferred to the facility hospital ED on a different campus. The Geropsych Director Y confirmed that the patient had been admitted to the facility without communication or consent of the patient's legal guardian and was not able to verify legal guardian communication of updated treatment needs or plans for the patient. Legal guardianship paperwork was documented in the medical record for patient #5 which identified the daughter as the guardian. On 4/4/23 at approximately 1600, Geropsych Director Y stated that the (incompetent) patient had signed the consent, the guardian should have been contacted, and that there would be immediate training and education.

On 4/5/23 at approximately 1330, review of the facility policy titled "Informed Consent Policy #1-113, revised 2/16/21" documented, "3.7. Informed Consent: A process that involves both an exchange of information between the healthcare provider and the patient and permission or assent from the patient. This includes information about the patient's medical condition, proposed course of treatment, risks and benefits of the proposed course of treatment and of non-treatment, prospects for recovery, and significant alternative treatment. Assent or permission from the patient will be documented on the appropriate consent form. 3.8. Legal Representative: A person appointed by the court to act for an Incapacitated Patient: a copy of 'letters of authority' (including 'letters of guardianship') issued by probate court, must be contained in the patient's medical record as evidence of the legal guardian's authority to give consent for the patient."